See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/317211451

The Effect of hand and foot massage on alleviating pain and anxiety of
abdominal post-operative patients at a University Hospital: A randomized
control trial

Article · May 2017

DOI: 10.9790/1959-0603035665

CITATIONS READS

0 595

2 authors, including:

Naglaa Youssef
Cairo University
18 PUBLICATIONS   18 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

HCV and DAA therapy View project

Egyptian Liver Library (ELL) View project

All content following this page was uploaded by Naglaa Youssef on 10 June 2017.

The user has requested enhancement of the downloaded file.

IOSR Journal of Nursing and Health Science (IOSR-JNHS)
e-ISSN: 2320–1959.p- ISSN: 2320–1940 Volume 6, Issue 3 Ver. III (May - June 2017), PP 56-65
www.iosrjournals.org

The Effect of hand and foot massage on alleviating pain and

anxiety of abdominal post-operative patients at a University
Hospital: A randomized control trial
Naglaa F.A. Youssef1* (PhD) & Asmaa Diab A. Hassan2 (DNS)
1&2
Lecturers at Medical-Surgical Nursing Department, Faculty of Nursing, Cairo University, Egypt

ABSTRACT:
Background: Controlling and relieving acute postoperative pain is one of the nurses' vital roles. Massage is an
independent nursing intervention that can be applied to a patient who is in pain. This study aimed to evaluate
the efficacy of hand and foot massage on alleviating pain and anxiety of patients who had abdominal surgery.
Methods: A randomized control trial was conducted over a period of eight months for 60 women who had
abdominal surgery. The participants were recruited from one of the big teaching hospitals in Cairo and quasi-
randomly allocated into the intervention or control group. The Numeric Rating Scale (NRS) and the State-Trait
Anxiety Inventory (STAI-form Y-2) were used alongside a background/medical data sheet to collect the data. A
foot and hand massage was performed for twenty-minutes for three days. Results: Although there was no
significant difference between the massage and control groups' pain intensity at baseline (Day-1-pre test)
(p>0.05), the intervention group had a significantly higher decrease in pain intensity than the control group
after applying a massage (p ≤ 0.000). Over 96% of the intervention group experienced moderate/severe anxiety,
while 100% of the control group experienced moderate/very severe anxiety at baseline with no significant
difference (p > 0.05). After the three sessions of hand and foot massage, the intervention group showed a
remarkably lower score of anxiety than the control group (p= 0.000). Conclusion: Hand and foot massage was
significantly associated with the reduction of pain and anxiety intensity. It can therefore be used as a
complementary method to reduce pain and anxiety in post-operative patients. A larger randomized study of
males and females is required to generalize the findings.
Key words
Abdominal surgery, anxiety, foot massage, hand massage, postoperative pain

I. Introduction
Pain is one of the most common complaints of postoperative patients worldwide. Despite the drugs and
anesthetic techniques available, the prevalence of post operative pain is still high [1]. For instance, about 41% of
postoperative patients experienced moderate to severe pain, even though sedative drugs had been administered
[2]. A large survey reported that of 300 patients, 86% experienced postoperative pain; of whom 75% had
moderate/severe pain during the immediate postsurgical period. Although about 88% received pain medications
80% of them experienced adverse effects and 39% reported moderate/severe pain even after receiving it [3].
Anxiety is another unpleasant feeling that affects postoperative patients emotionally, psychologically
and physically. Facing surgery may cause some normal anxiety-related behavior, but health care providers
should monitor the patient’s anxiety level to preclude the development of an anxiety disorder [2]. Anticipated
postsurgical pain was the most prominent pre-surgical patient concern, and nearly half the patients reported a
high anxiety level about anticipated pain before surgery [3].
Additionally, acute postoperative pain is often still ineffectively managed. The poor management of
postoperative pain may increase the risk for patients to develop physiological responses to pain, which produce
harmful effects on the body after surgery [4] or even develop chronic pain conditions in some vulnerable
patients [5]. For instance, 74% of 300 postoperative patients were still experiencing high levels of pain after
their discharge from hospital [3].
Varieties of pharmacological and non-pharmacological interventions to enhance optimal pain relief are
available; however, patients' responses are individualized [6]. Pain medication is still the current gold standard
treatment for acute postoperative pain relief [7]. However, there is an increasing global interest in applying
alternative modalities and non-pharmacological approaches for pain and anxiety relief to overcome the adverse
effects of medication, such as massage.

1.1 Significance of the study

Pain management is a complex yet essential function for health care providers. Effective pain
management is crucial for individuals following surgery to provide comfort, prevent complications and boost
recovery [8]. Massage is an independent nursing intervention that can be applied to patients in pain. Massage is
DOI: 10.9790/1959-0603035665 www.iosrjournals.org 56 | Page
 The Effect of hand and foot massage on alleviating pain and anxiety of abdominal post-operative

easy to apply, cheap and no special equipment is needed. It could be embedded into daily nursing activities.
However, a pertinent question is whether foot and hand massage relieves acute postoperative pain in patients
after abdominal surgery. A critical analysis needs to determine its effect on relieving acute postoperative pain.
Providing safe, effective pain management is a concern for all nurses caring for patients following surgery.
Registered nurses at all levels of practice are primarily patient advocates who have a vital role in managing
postoperative pain appropriately [8]. Massage therapy was found as essential element of the patients' healing
experience after surgery [9]. Postoperative cardiac patients who received a foot massage were highly satisfied
with the intervention and no barriers to implementing massage therapy were identified [9]. A growing body of
literature supports the application of massage therapy in post operative open heart surgery patients [2; 10].
However there is a shortage of knowledge regarding the effect of foot and hand massage on postoperative
abdominal surgery.
The researchers observed in their clinical practice that postoperative pain and anxiety levels, especially
in the days following surgery, were high; and the prescribed pain killers could not relieve the pain completely.
Hence, it was worth to investigate the effect of hand and foot massage on relieving pain and anxiety symptoms
in postoperative patients to establish evidence of its effectiveness and safety among these patients.

Aim and Hypotheses

This study aimed to examine the efficacy of hand and foot massage on alleviating pain and anxiety of patients
who had abdominal surgery.

These two hypotheses were tested:

H1: The mean of pain score will be significantly lower in the study group who receive hand and foot massage
than in the control group who receive traditional care only.
H2: The mean of anxiety score will be significantly lower in patients who receive massage therapy than in
patients who do not receive it.

1.2 Theoretical framework

Tissue damage is the main cause of postoperative pain, since it induces the release of chemical
mediators from the surgical wound [7]. Understanding the mechanism of massage and how it works on the body
is essential to recognize how to acquire its benefits and achieve the end outcomes. Numerous theories explain
how massage therapy affects the body. The "gate control theory" (GCT), developed by Melzack and Wall
(1965), is the best to explain the mechanism of controlling pain. [11]. GCT proposes gated circuits, which are
located in the superficial dorsal horn of the spinal cord, through which pain is generated and controlled. GCT
suggests that pain impulses are regulated by gating mechanism along the central nervous system (CNS). They
occur in the spinal cord, sites in the thalamus and limbic system. According to this theory pain impulses pass
through the CNS when the gate is open, but not while it is closed. The gating mechanism either permits or
inhibits the transmission of pain impulses. If large fibers (A-alpha & A-beta) are stimulated, pain transmission is
inhibited and the gate is closed. Large nerve fibers and dermatome layers contain tactile and pressure receptors,
which can be stimulated by massage. These receptors consequently transfer the nerve impulses to the CNS.
Therefore, GCT stipulates that massage provides stimulation which blocks or interrupts the pain signals sent to
the brain. Massage can also stimulate the release of certain chemical substances in the body such as serotonin,
which inhibits the transmission of noxious nerve signals to the brain, or endorphins, which make the body more
relaxed [11; 12].

II. Materials And Methods

1.3 Design
A randomized control trial design was utilized to accomplish this study.
1.4 Population and Sample
A sample of 60 patients who had general abdominal surgery was recruited over a period of eight months
(August 2016 to March 2017). Patients were quasi-randomly allocated into a control group (n = 30), and a
massage group (n = 30) according to even or odd hospitalization admission code number.

Inclusion criteria
Patients who met the following inclusion criteria were invited to participate in this study:
• Adults ≥ 18 years old
• Have the ability to answer the interviewer's questions
• Give informed consent and are hemodynamically stabilized
• Had abdominal surgery
• Received general anesthetics.

DOI: 10.9790/1959-0603035665 www.iosrjournals.org 57 | Page

 The Effect of hand and foot massage on alleviating pain and anxiety of abdominal post-operative

Exclusion criteria
Patients were excluded from this study if they had any of the following:
• History of chronic pain
• Metastasis cancer, on narcotic medication
• Hand or foot amputation
• Wound on foot/hand, dementia, or psychiatric diagnosis
• Diagnosis of deep vein thrombosis, adrenal gland disorder, skin problems, dialysis fistula
• History of bone fracture in the past two months
• Previous history of message therapy
• Receiving warfarin
• Edema or ulcers in extremities
• Cardiac arrest during the past 72 hours
• Infectious diseases (skin, viral hepatitis, jaundice)
• History of second degree burn on more than 25% of the body surface
• Any problems related to blood vessels, diabetes
• Hypersensitivity to hand and foot massage
• Dependence on oxygenation apparatus
• Completely bedridden for a long time (risk of DVT).

1.5 Setting
The study was conducted in a general surgery wards in a teaching hospital in Cairo. This hospital is one of the
largest public teaching hospitals in the Cairo region, where a great number of patients from different socio-
demographic and economic backgrounds come to receive health care from different regions in Egypt.

1.6 Measurements
Socio-demographic and medical data sheet
The sheet had two parts, patients' characteristics and medical data, and it was used to collect the patients'
characteristics such as age, gender, education and employment status. The medical data sheet was used to record
the diagnosis, type of surgery, etc. The history of analgesic consumption was collected from the patient’s
medical records.
Numeric Rating Scale (NRS) for pain
The Pain Visual Analogue Scale (VAS) is the commonly used standardized pain measurement scale, which
measures pain intensity. However, its test–retest reliability has been shown higher among literate (r = 0.94) than
illiterate patients (r = r = 0.71) [13]. Numeric Rating Scale (NRS) is a segmented numeric version of the VAS,
and it has a single 11-point numeric scale in which respondents select a number from 0 (no pain) to 10 (sever
pain) to reflect the intensity of their pain. NRS has high test–retest reliability in both literate and illiterate
patients (r = 0.96 & 0.95, respectively) [13]. Therefore, NRS was used in this study to assess the pain intensity
before and after each massage session. The patients were requested to select the number that represents their
pain intensity. The overall score of the NRS ranges from 0–10, and it can also describe pain intensity as no pain
(0), mild pain (1-3), moderate pain (4-6), and severe pain (7-10).
Spielberger’s State-Trait Anxiety Inventory (STAI)
The State-Trait Anxiety Inventory (STAI) was developed and used by Spielberger, Gorsuch, Lushene, Vagg,
and Jacobs (1983) [14]. This scale has two inventories, 20 items for each: (1) State anxiety (STAI Form Y-1/S-
AI) measures the subjective experience of fear, nervousness and anxiety of current or recent times or scenes, as
well as stress-state anxiety; (2) Trait anxiety (STAI Form Y-2/T-AI) measures the normal anxiety level. Only
form Y-1/ STAI was used in this study to examine state anxiety, which ranged from 1-not at all; 2-sometimes;
3-moderately so and 4-very much so. By adding 20 items the total score was obtained. Phrases which showed a
lack of anxiety were scored in reverse order. Scores of 20-42, 43-53, 54-64 and 65-75 were interpreted as mild,
moderate, severe and very severe anxiety respectively, a higher score indicating a greater anxiety level. Y-1/
STAI has proofed to have a high reliability, alpha = 0.86-0.90 [14]. The Arabic version, which has its validity
and reliability well established among the Egyptian population was used, coefficient > 0.80 [15]. Official
permission to use this scale was obtained from www.mindarden.com.

1.7 Intervention
Swedish massage is the most commonly used type of massage therapy, which is often known as light
or relaxation massage. Swedish massage therapy increases the circulation, which helps the body to be more
relaxed and energized by relieving muscle tension and pain, thus increasing overall health and well-being.
Swedish massage includes effleurage, petrissage, tapotement and friction techniques. Effleurage influences the
superficial tissues and is used to apply the lubricant, spreading it over the surface. It aims to warm the surface

DOI: 10.9790/1959-0603035665 www.iosrjournals.org 58 | Page

 The Effect of hand and foot massage on alleviating pain and anxiety of abdominal post-operative

layer of the tissue to create relaxation before applying other techniques. Petrissage is the kneading that follows
effleurage. Tapotement (i.e. beating percussion) is a rhythmic short taps’ application done with cupped hands,
fingers, or the edge of the hand. Friction consists of deep and circular movements, which aim to rub the layers of
tissue against each other in order to increase blood flow [16; 17].

These steps were followed to apply the massage technique mentioned above [17]:
1. Effleurage was used to spread the lubricant (olive oil) over the participant's hands and feet by massaging
from the base of the fingers to the wrist or from the toes to the ankle.
2. Petrissage as a short, gentle and rapid movement was used to squeeze, roll or knead the hands, feet, fingers
and toes.
3. Tapotement (i.e. beating or percussion) was used as short taps done with the fingers.
4. Friction was used to rub the layers of tissues against each other in order to increase blood flow.
The intervention group followed the routine ward care and in addition received 20 minutes of hand and foot
massage, 5 minutes for each extremity, at a time for three days; while the control group followed the routine
ward care, and received 20 minutes of rest time (to control for emotional reaction).

2.6 Ethical considerations

This study was conducted in accordance with the Helsinki Declaration. Official permission was obtained
from the director of the hospital and surgical wards before data collection. Before obtaining the patients'
consent, they were informed about the purpose and nature of the study. Their participation in the study was
entirely voluntary and withdrawal from the study was permitted at any time with no effect on their care. The
patient’s anonymity and confidentiality was assured by coding the data with hidden identifying data such as a
name.

1.7 Pilot study

A pilot study was conducted on five patients, who were then excluded from the main study sample. The
pilot study aimed to: (i) estimate the required sample size (ii) calculate the time necessary to interview the
patients, (iii) test the clarity and understandability of the questionnaires and (iv) examine the feasibility of the
massage technique.
All questionnaires items were clear, understandable and no modification was required. Using an
antiseptic solution to care for the feet before the massage was not acceptable to many patients. Therefore, it was
decided to wash the feet by using only water and wearing gloves before demonstrating the massage. The results
of the pilot study confirmed that the study was feasible.

1.8 Procedure of data collection

 Interview of the patient to explain the study in order to receive informed consent.
 Review of the patient’s medical history to consider who meets the inclusion criteria.
 Check with the physician whether the patient has any of the contraindications to participate in the study.
 The patients were met over three consecutive days to do the following:
o First time (T-0) to complete the questionnaires (demographic data sheet, pain NRS and STAI), and first
application of the hand and foot massage, which followed by recomplete the NRS.
o Second time (T-1) to re-complete the pain NRS questionnaire pre & post application of the hand and foot
massage and
o Third time (T-2) to re-complete the pain NRS pre & post application of the hand and foot massage
The anxiety intensity using STAI was assessed only twice: at baseline [(T-0) pre massage] and post-
test [(T-2) post massage].
The intervention group received 20 minutes of hand and foot massage per day for three consecutive days in the
afternoon. Patients in the control group received routine hospital care only. The massage was initiated on the
second day post-operatively to be dynamically stabilized. The assessment of baseline data and the massage were
applied at least three hours after analgesics administration.
1.9 Statistical data analysis
Data were analyzed using SPSS statistical software version 20. Continuous data obtained before and after
the massage for the three days were expressed as mean ± standard deviation (SD). Categorical data were
expressed in numbers and percent. The independent t-test was used to investigate the differences between two
groups and the paired t-test was used to determine the differences pre and post massage application in each
group. Changes in the pain and anxiety score were assessed using one way repeated measures analysis of
variance (ANOVA). The Mann-Whitney test was used for variables that did not meet the parametric
assumptions. The chi-square test was used to analyze the relationship between two variables in case of non-
continuous data. P value < 0.05 was accepted as statistically significant.

DOI: 10.9790/1959-0603035665 www.iosrjournals.org 59 | Page

 The Effect of hand and foot massage on alleviating pain and anxiety of abdominal post-operative

III. Results
The study results are presented in three sections: (1) Description of the study subjects' socio-
demographic characteristics and related medical information, (2) Comparison of pain intensity at T-0, T-1 and
T-2 between control and intervention groups, and (3) Comparison of state anxiety intensity at T-0 and T-2
between control and intervention groups.
The mean age of the 60 participants was 40.37±10.34 years, in the intervention group it was
38.07+11.39 years, whereas in the control group it was 42.67+8.76 years; however there was statistically no
significant difference between both groups (P = 0.085). TABLE 1 also shows that there is statistically no
significant difference between the two groups in education, marital status, employment status and smoking
habits (P > .05) which was calculated by chi-square test. However, there was a significant difference in the types
of surgery in the two groups (Chi-square = 8.92, p = 0.01). The control group had a higher prevalence of
herniectomy than the intervention group (53.3% vs. 23%); while the intervention group had a higher prevalence
of cancer colon, intestinal obstruction and stomach sleeve surgeries (see Fig. 1).

TABLE (1): Comparison Between Intervention And Control Groups' Characteristics (N=60).
Characteristics Intervention group (n=30) Control group (n=30) Pearson Chi-
N % N % square/t test
(p value)
Age (mean ± SD) 38.07+11.39 42.67+8.76 0.08
(20-65) (22-55)
Gender 30 100% 30 100% -----
 Female
Marital status
 Unmarried 5 16.7% 4 13.3% 0.13 (0.72)
 Married 25 83.3% 26 86.7%

Education level
 Uneducated
 Can read & write
 Primary/preparatory school
 Secondary/diploma school
 Higher education
4 13.3% 1 3.3% 7.78 (0.10)
7 23.3% 17 56.7%
8 26.7% 4 13.3%
8 26.7% 6 20.0%

3 10.0% 2 6.7%
Employment status
 Yes 13 43.3% 19 63.3% 2.41 (0.12)
 No 17 56.7% 11 36.7%

60
53.3
50
40
40 36.7 36.7
Percentage
30
23
20
10
10

0
Intervention Control

Herniectomy cholecystectomy Other

Figure (1): Distribution of Surgery Type of Intervention and Control Groups

TABLE 2 presents the one way repeated measure ANOVA which compares the pain intensity scores at
T-0 (prior to the massage at day 2 after surgery), T-0 (following the massage at day 2 after surgery), T-1
(following the massage at day 3 after surgery) and T-2 (following the massage at day 4 after surgery). The
DOI: 10.9790/1959-0603035665 www.iosrjournals.org 60 | Page
 The Effect of hand and foot massage on alleviating pain and anxiety of abdominal post-operative

results show that the mean score of pain intensity in the intervention group before and after the hand and foot
massage had changed significantly (p = 0.000). Also, the mean score of pain intensity in the control group
before and after routine care had changed significantly (p = 0.000). There was a significant effect of time on
pain intensity in the intervention and control groups, where Wilks' Lambda = 0.10 & 0.20 respectively and
multivariate partial eta squared = 0.90 & 0.80 respectively.

FIGURE (2): Pattern of Change In Pain Intensity In The Intervention And Control Groups

Fig.2 illustrates the pattern of change in pain intensity at three measurement points (baseline, T-1 and T-2) in the
intervention and control groups. Interestingly, although both groups had a significant decrease in pain intensity
at the three measurement points (p ≤ 0.05), the massage intervention group had a higher decrease of pain
intensity than the control group, as the mean score illustrates.

Table (2): Comparison of Baseline And Post-Test Pain Scores In The Intervention And Control Groups Using
Repeated Measures Anova
Variable Pretest (T-0) Posttest (T-0) Posttest (T-1) Posttest (T-2) F p
Mean ± SD
Pain (intervention group) 8.10±1.18 4.70±1.89 3.20±1.80 1.66±1.97 75.95 0.000
n= 30
Pain (control group) n= 30 8.43±.73 7.83±.74 7.20±.80 6.66±.88 35.00 0.000

TABLE 3 compares the intervention and control groups' pain intensity over time (for three days measurements).
Although there is no significant difference between the two groups' pain intensity at baseline (Day-1-pre test) (p
= 0.16), there is a significant difference between them at the other points of measurement (p = 0.000).

TABLE (3): Comparison Of Intervention And Control Groups' Pain Intensity Over Time, Independent-T Test
(Mann-Whitney Test)
Variable Time of measure Intervention group (n = Control group p. value
30) (n = 30)
Mean rank Mean rank
Pain intensity Day-1
Pre massage 27.47 33.53 0.160
Post massage 17.32 43.68 0.000
Day-2
Pre massage 20.10 40.90 0.000
Post massage 16.82 44.18 0.000
Day-3
Pre massage 19.22 41.78 0.000
Post massage 16.47 44.53 0.000

DOI: 10.9790/1959-0603035665 www.iosrjournals.org 61 | Page

 The Effect of hand and foot massage on alleviating pain and anxiety of abdominal post-operative

Fig.3 shows the change in anxiety intensity at two points of measurement (baseline and T-2) in the intervention
and control groups. Interestingly, although both groups have a significant decrease in anxiety intensity between
pre and post massage, the massage intervention group has a greater decrease of anxiety intensity than the control
group.

60
Mean of anxiety score

50
40
30
20
10
0
Pre massage-T0 Post massage-T2
Intervention 51.3 56.67
Control group 35.1 50.13

FIGURE (3): Change In Anxiety Intensity In The Intervention And Control Groups

TABLE 4 shows the distribution of patients according to their anxiety level at T-0 and T-2. The results of the
STAI scale reveal that 96.7% of the intervention group experienced moderate to severe anxiety, while 100% of
the control group experienced moderate to very severe anxiety at time 0. However, there is no significant
difference between the massage and control groups at T-0 (p = 0.51). At T-2, after the three massage sessions,
the massage group has a remarkably lower anxiety score than the control group (p= 0.000).

TABLE (4): Comparison Of The Intervention And Control Groups' State Anxiety Over Time, Independent-T
Test (Mann-Whitney Test)
Variable Time of Intervention group Control group Independent t-test
measure (n=30) (n=30) (P. value)
Anxiety level % Mean Anxiety level % Mean
rank rank
Anxiety T-0 baseline Mild = 3.3 26.12 Moderate = 23.3 34.88 0.51
intensity Moderate = 50.0 Severe = 73.3
Severe = 46.7 Very severe = 3.3
T-2 2nd measure Mild = 83.3 19.53 Mild = 30.0 41.47 0.000
Moderate = 13.3 Moderate = 30.0
Severe = 3.3 Severe = 36.7
Very severe = 3.3

IV. Discussion
Pain is one of the commonly experienced symptoms by patients with acute and chronic conditions [7].
Nurses have a crucial role to control postoperative pain. The two methods most commonly used for pain control
are pharmacologic and non-pharmacologic. However, the pharmacological approach may not entirely relieve all
aspects of postoperative pain. Therefore, non-pharmacological methods such as massage may potentially relieve
postoperative pain [7]. A review conducted by [7] concluded that foot massage as one of the complementary
therapies proved to decrease the pain level in patients with acute postoperative pain. Anxiety is another related
unpleasant feeling that affects postoperative patients emotionally, psychologically and physically. It is
characterized by a feeling of threat that could be real or unreal [2]. Therefore, our study aimed to investigate the
effects of hand and foot massage on relieving pain and anxiety symptoms in postoperative patients. The study's
findings are discussed in three sections: (1) Study subjects' socio-demographic characteristics and related
medical information, (2) Comparison of pain intensity at three time points in the control and intervention
groups, and (3) Comparison of state anxiety intensity at three time points in the control and intervention groups.
(1) Study subjects' socio-demographic characteristics and related medical information
Sixty patients with abdominal surgery participated in this study. They were quasi-randomly distributed into an
intervention and control group. There was no significant difference between the two groups in terms of their
socio-demographic and medical data, although the type of surgery was significantly different. However, the
baseline of pain and anxiety intensity was the same in the two groups.
DOI: 10.9790/1959-0603035665 www.iosrjournals.org 62 | Page
 The Effect of hand and foot massage on alleviating pain and anxiety of abdominal post-operative

Only women participated in the current study, as gender as an extraneous variable has been found
related to the response of pain management. Gender is an important factor in the response not only to
postoperative pain but also to anesthetics and pain management. For instance, it has been reported that males
wake up more slowly than women after general anesthesia and that they have fewer postoperative gastro-
intestinal disturbances [18]. The literature supports that males and females differ in their response to pain, as
higher pain sensitivity is commonly observed in females. Females' sexual hormones seem to be linked to these
differences [18; 19]; however, further studies are needed to explain the underlying mechanisms, including the
contribution of hormonal and genetic factors [19]. The response to pharmacological and non-pharmacological
pain management in males and females is still under investigation. Women reported more pain in more bodily
areas with greater frequency and for a longer duration than men [20]. Our study sample was all females, which
may also explain why the majority in our study were non-smokers.
Pain medication is considered a confounding variable because each medicine has different
pharmacokinetic and pharmacodynamic properties. According to previous research, these drugs give different
responses to patients’ pain; research studies need to control the effect of pain medication, for example by having
similar pain medication given to each patient [7]. In the current study, all participating patients routinely took
non steroidal anti-inflammatory (NSAI) pain medication which provided the same analgesic effect. Also to
control any pain medications effect; the assessment of baseline data and the massage were applied at least three
hours after analgesics administration.

(2) Comparison of pain intensity at three points in time in the control and intervention groups
In relation to pain intensity, the current study's results show that the mean score of pain intensity
significantly decreased in the intervention group who received hand and foot massage in comparison to the
control group who received only routine care. This finding is consistent with previous studies, which support
our results that pain severity significantly decreased in the intervention group compared to the control group. All
had abdominal surgery, but the intervention groups had 20 minutes of hand and foot massage (effleurage and
kneading) on three days [21]. In postoperative patients, 20-minutes of foot and hand massage significantly
reduced both pain intensity and pain distress resulting from the wound on the first postoperative day [22].
Interestingly, in women who had a hysterectomy there was a significant reduction in pain in the experimental
group following a hand and foot massage compared to the control group [23]. Additionally, foot and hand
massage was effective in decreasing postoperative pain in open heart surgery patients [24]. This indicates that
whatever the surgery type, massage is effective in decreasing postoperative pain.
It is essential to highlight the important findings in the current study are congruent with previous
studies [21]. As our results show, hand and foot massage could help to decrease pain intensity and gave some
amount of comfort to the patients. A review study that aimed to identify the effect of foot massage on relieving
acute postoperative pain recommended that pharmacologic and non-pharmacologic management be used
together to relieve pain. Using a pharmacologic approach alone may not fully relieve all aspects of acute
postoperative pain [7].
Current evidence supports that massage has promising safe effects for the alleviation of pain, tension
and anxiety. Bauer and colleagues [9] investigated the effect of foot massage versus relaxation on postoperative
back and shoulder pain, anxiety and tension in a randomized group of cardiac surgery patients. Their results
show that patients receiving massage therapy had a significant decrease in pain, anxiety and tension.
Additionally, massage versus vibration therapy was tested [25] for short-term postsurgical pain, negative affect
and physiologic stress reactivity on a randomized sample of women who underwent an abdominal laparotomy
for the removal of suspected cancerous lesions. The results showed that on the day of surgery, massage was
more effective than the usual care (UC) for affective and sensory pain, and better than vibration therapy for
affective pain. On postoperative day 2, massage was more effective than UC for distress, and better than
vibration therapy for sensory pain. However, after controlling for multiple comparisons and multiple outcomes,
no significant differences were found [25]. Several studies showed the efficacy of foot massage to decrease
acute postoperative pain [26; 22]. Our study findings support the efficacy of massage on relieving pain, where
skin contact by massage is effective in relieving pain and anxiety.

(3) Comparison of state anxiety intensity at two points in time in the control and intervention groups
Our study findings show that there was no significant difference between the intervention and control
groups regarding anxiety intensity before the massage. However, the anxiety level was significantly decreased
in the intervention group, who received hand and foot massage along with routine care, as compared to the
control group, who received only routine care. This difference indicates the positive effect of hand and foot
massage on decreasing the anxiety intensity after surgery. Our findings are similar to previous studies that
examined the effect of 20 minutes massage therapy on pain, anxiety and tension in cardiac surgical patients. The
anxiety score significantly decreased in those patients who received massage alongside standard care [9; 27]. A

DOI: 10.9790/1959-0603035665 www.iosrjournals.org 63 | Page

 The Effect of hand and foot massage on alleviating pain and anxiety of abdominal post-operative

previous study also showed that those patients who received massage therapy were highly satisfied with the
intervention and no major barriers to its implementation were observed [27]. These results suggest that massage
therapy is an important, safe and effective non-pharmacological intervention that should be considered for
inclusion in the management of postoperative recovery of surgical patients [10].
A recent review [10] of patients in the intensive care unit concluded that applying massage therapy as a
non-pharmacological method at least once a day for 20 min in the early days after cardiac surgery confirmed a
remarkable reduction in the pain and anxiety score. However, large and high quality randomized control trials
are needed to examine further important outcomes in the recovery of surgical patients.

V. Conclusion
This study's findings concluded that pain and anxiety are commonly experienced symptoms in the
majority of postoperative patients. Hand and foot massage as a non-pharmacological nursing intervention
showed a significant impact on decreasing these symptoms. An increase in nurses' awareness about the
importance of applying massage after surgery can relieve the feelings of pain and anxiety in many of these
patients. Also, nurses have a vital role in enhancing the knowledge and skills of post-operative patients and their
caregivers through teaching sessions of how to use massage to relieve pain and anxiety after surgery.

VI. Implications And Recommendations

Using hand and foot massage in surgical patients has notable effects on decreasing pain intensity and
anxiety levels post-operatively. With decreasing pain intensity and anxiety levels patient complaints will also
decrease and their satisfaction with the delivered healthcare will be increased. At the same time, post-operative
complications associated with the increased intensity of pain and anxiety will decrease. Based on this study's
findings we recommend the following:
1. Patients undergoing general abdominal surgery should be provided with a simple and applicable strategy to
control pain and anxiety.
2. The assessment of preoperative anxiety should be recorded in the patient’s medical records in order to
provide a baseline for comparison with post-operative anxiety levels.
3. Healthcare providers, especially nurses, should frequently assess the patient’s pain and teach the patient
non-pharmacological strategies, such as massage, to relieve it.
4. A systematic pain assessment can be integrated into the daily routine of nurses. Frequent assessment of
pain has been found to be useful information that helps healthcare providers in making appropriate
decisions on managing pain [6].
5. The development of an educational program to improve nurses' knowledge of pain and how to manage it
using non-pharmacological interventions is required.

VII. Limitations
Further studies are required to assess patients' satisfaction with massage therapy and its association with
potential post-operative complications such as wound healing and length of hospital stay. There is a need to
replicate this study on a larger randomized trial on adult males and females to achieve more generalizable
results.
Acknowledgements

The authors would like to express their gratitude to all the patients who accepted to participate in this study. We
also extend our thanks to all respectful medical and nursing staff for helping us in conducting this study.

Conflict of Interest
The authors declare no conflict of interest.

References
[1] Hoogervorst-Schilp J, van Boekel RL, de Blok C, Steegers MA, Spreeuwenberg P, Wagner C. Postoperative pain assessment in
hospitalised patients: National survey and secondary data analysis. International Journal of Nursing Studies. 2016 Nov 30;63:124-
31.
[2] Kaur S, Lobo DJ, Latha T. Role of foot and hand massage on the anxiety for post operative open heart surgery patients: A
Randomized Control Trial. International Journal of Nursing Education. 2013 Jul 1;5(2):205.
[3] Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL. Incidence, patient satisfaction, and perceptions of post-surgical pain:
Results from a US national survey. Current Medical Research and Opinion. 2014 Jan 1;30(1):149-60.
[4] Asadizaker M, Fathizadeh A, Haidari A, Goharpai S, Fayzi S. The effect of foot and hand massage on postoperative cardiac surgery
pain. International Journal of Nursing and Midwifery. 2011 Oct 30;3(10):165-9.
[5] Deumens R, Steyaert A, Forget P, Schubert M, Lavand’homme P, Hermans E, De Kock M. Prevention of chronic postoperative
pain: Cellular, molecular, and clinical insights for mechanism-based treatment approaches. Progress in neurobiology. 2013 May
31;104:1-37.

DOI: 10.9790/1959-0603035665 www.iosrjournals.org 64 | Page

 The Effect of hand and foot massage on alleviating pain and anxiety of abdominal post-operative
[6] Van Dijk JF, Vervoort SC, Van Wijck AJ, Kalkman CJ, Schuurmans MJ. Postoperative patients’ perspectives on rating pain: A
qualitative study. International journal of nursing studies. 2016 Jan 31;53:260-9.
[7] Chanif C, Petpichetchian W, Chongchareon W. Does foot massage relieve acute postoperative pain? A literature review. Nurse
Media Journal of Nursing. 2013 Jan 31;3(1):483-97.
[8] Ward CW. A decision tree model for postoperative pain management. Urologic Nursing. 2015 Sep 1;35(5):251-7.
[9] Bauer BA, Cutshall SM, Wentworth LJ, Engen D, Messner PK, Wood CM, Brekke KM, Kelly RF, Sundt TM. Effect of massage
therapy on pain, anxiety, and tension after cardiac surgery: a randomized study. Complementary Therapies in Clinical Practice.
2010 May 31;16(2):70-5.
[10] Miozzo, A.P., Stein, C., Bozzetto, C.B. and Plentz, R.D.M., 2016. Massage therapy reduces pain and anxiety after cardiac surgery:
A systematic review and meta-analysis of randomized clinical trials. Clinical Trials and Regulatory Science in Cardiology, 23, pp.1-
8.
[11] Melzack R, Wall PD. Pain mechanisms: A new theory Science, (1965), 150: 971–979
[12] Moyer, CA., Rounds, J. and Hannum, JW., 2004. A meta-analysis of massage therapy research. Psychological Bulletin, 130(1),
pp.3-18. http://dx.doi.org/10.1037/0033-2909.130.1.3
[13] Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for pain (VAS pain), Numeric Rating
Scale for pain (NRS pain), McGill Pain Questionnaire (MPQ), Short‐Form McGill Pain Questionnaire (SF‐MPQ), Chronic Pain
Grade Scale (CPGS), Short Form‐36 Bodily Pain Scale (SF‐36 BPS), and Measure Of Intermittent And Constant Osteoarthritis Pain
(ICOAP). Arthritis Care & Research. 2011 Nov 1;63(S11):S240-52.
[14] Spielberger, CD. Gorsuch, RL, Lushene, R, Vagg, PR, Jacobs, G., Manual for the state-trait anxiety inventory (form Y1). 1983.
Palo Alto, CA: Consulting Psychologists.
[15] Abdel-Khalek, A.M., 1989. The development and validation of an Arabic form of the STAI: Egyptian results. Personality and
Individual Differences, 10(3), pp.277-285.
[16] Stone, V., 2010. The world's best massage techniques the complete illustrated guide: Innovative bodywork practices from around
the globe for pleasure, relaxation, and pain relief. Fair Winds Press.
[17] Salvo, S.G., 2015. Massage therapy: Principles and practice. Elsevier Health Sciences.
[18] Keogh E, McCracken LM, Eccleston C. Do men and women differ in their response to interdisciplinary chronic pain management?.
Pain. 2005 Mar 31;114(1):37-46.
[19] Bartley EJ, Fillingim RB. Sex differences in pain: a brief review of clinical and experimental findings. British Journal of
Anaesthesia. 2013 Jul 1;111(1):52-8.
[20] Campesi I, Fois M, Franconi F. Sex and gender aspects in anesthetics and pain medication. In sex and gender differences in
pharmacology 2013 (pp. 265-278). Springer Berlin Heidelberg.
[21] Joy C, Arora S, Tamang EL. A Study to assess the effectiveness of foot massage on pain among patients after abdominal surgery in
a selected hospital of Delhi. International Journal of Nursing Education. 2014;6(2):112-6.
[22] Wang HL, Keck JF. Foot and hand massage as an intervention for postoperative pain. Pain Management Nursing. 2004 Jun
30;5(2):59-65.
[23] Chithra PN, D'Almeida S. Effectiveness of hand and foot massage on pain among women who have undergone abdominal
hysterectomy in selected hospitals at Mangalore. Asian Journal of Nursing Education and Research. 2014 Jul 1;4(3):337.
[24] Kaur S, Lobo DJ, Latha T. Effectiveness of hand-foot massage on the post operative pain among open heart surgery patients: A
randomised control trial. In Worldwide Nursing Conference (WNC) 2014 Jul 21.
[25] Taylor AG, Galper DI, Taylor P, Rice LW, Andersen W, Irvin W, Wang XQ, Harrell Jr FE. Effects of adjunctive Swedish massage
and vibration therapy on short-term postoperative outcomes: A randomized, controlled trial. The Journal of Alternative &
Complementary Medicine. 2003 Feb 1;9(1):77-89.
[26] Kim JH, Park KS. The effect of foot massage on post operative pain in patients following abdominal surgery. Journal of Korean
Academy of Adult Nursing. 2002 Mar 1;14(1):34-43.
[27] Cutshall SM, Wentworth LJ, Engen D, Sundt TM, Kelly RF, Bauer BA. Effect of massage therapy on pain, anxiety, and tension in
cardiac surgical patients: A pilot study. Complementary Therapies in Clinical Practice. 2010 May 31;16(2):92-5.

DOI: 10.9790/1959-0603035665 www.iosrjournals.org 65 | Page

View publication stats